Blunt selenic injury in adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma

Background: Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nono perative management are controversial. The purpose of this multi-institutio nal study was to determine which factors predict successful observation of blunt splenic injury in adults. Methods: A total of 1,488 adults (>15 years of age) with blunt splenic inju ry from 27 trauma centers in 1997 were studied through the Multi-institutio nal Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended c hi(2) test. Data are expressed as mean +/- SD; a value of p < 0.05 was cons idered significant. Results:A total of 38.5 % of patients went directly to the operating room ( group I); 61.5% of patients were admitted with planned nonoperative managem ent. Of the patients admitted with planned observation, 10.8% failed and re quired laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequenc y of immediate operation correlated with American Association for the Surge ry of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (3 8.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of s plenic injury: I (4.8%), TI (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Lapa rotomy was ultimately performed in 19.9% of patients with small hemoperiton eum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum. Conclusion: In this multicenter study, 38.5% of adults with blunt splenic i njury went directly to laparotomy. Ultimately, 54.8% of patients were succe ssfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hemat ocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of sp lenic injury, and quantity of hemoperitoneum.